Basic Information
| Provider Information | |||||||||
| NPI: | 1902897051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FALLOON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 42499 | MN | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 140007661 | 01 | RR MEDICARE | OTHER | 996067 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 85D65FA | 01 | BLUE CROSS BLUE SHIELD | OTHER | 0600040 | 01 | MEDICA HEALTH PLANS | OTHER | 1927405 | 01 | FIRST HEALTH PLAN | OTHER | 127844 | 01 | U CARE | OTHER | 1023510 | 01 | PREFERRED ONE | OTHER | 480677800 | 01 | MEDICAL ASSISTANCE | OTHER | CI1369 | 01 | RR MEDICARE | OTHER | HP30505 | 01 | HEALTH PARTNERS | OTHER |